Pellico: Chapter 30 (Diabetes Mellitus) Flashcards Preview

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1

Diabetes mellitus

-A group of metabolic diseases characterized by elevated levels of glucose in the blood (hyperglycemia)

-Chronic Disease

2

What other diseases are associated with diabetes mellitus?

1.) Hypertension

2.) Heart Disease

3.) Stroke

4.) Leading cause of nontraumatic amputations

5.) Blindness (in working age adults)

6.) End-stage Renal Disease (ESRD)

3

What percentage of the U.S. population has Diabetes mellitus?

-Approximately 8% of the population (24 million people)

-About 24% of those with Diabetes mellitus remain undiagnosed! (This means that detection is an important goal)

4

How many people in the United States have prediabetes?

Approximately 57 million people in the United States have prediabetes (that's almost 18% of the population!)

5

What is the age trend for diabetes mellitus?

  • The occurrence of diabetes, especially type II, is increasing in ALL age groups
  • Diabetes is expecially prevalent in persons over the age of 60

6

Describe the four different types of diabetes mellitus.

  1. Type I Diabetes
  2. Type II Diabetes
  3. Gestational Diabetes
  4. Secondary Diabetes

7

What is Type I Diabetes mellitus?

Previous Classifications/Names: Juvenile diabetes, Juvenile-onset diabetes, Ketosis-prone diabetes, Brittle diabetes, Insulin-depiendent diabetes mellitus

Clinical Characteristics:

  • Onset any age, but usually young (<30)
  • Usually thin at diagnosis; recent weight loss
  • Genetic, immunologic, and environmental etiology (virus)
  • Often have islet cell antibodies
  • Often have antibodies to insulin even before insulin treatment
  • Little/no endogenous insulin
  • NEED insulin to preserve life
  • Ketosis-prone when insulin is absent
  • Diabetic ketoacidosis (acute complication of hyperglycemia)

8

What is Type II Diabetes mellitus?

Previous Classifications: Adult-onset diabetes, Maturity-onset diabetes, Ketosis-resistant diabetes, Stable diabetes, Non-insulin-dependent diabetes (NIDDM)

Characteristics:

  • Onset any age; usually over 30 years
  • Usually obese at diagnosis
  • Causes include obesity, heredity, and environmental factors
  • NO islet cell antibodies
  • Decreased endogenous insulin; OR increased with insulin resistance
  • Most patients can control blood glucose through weight loss if obese
  • Oral antidiabetic agents may improve blood glucose if lifestyle interventions are unsuccessful
  • May need insulin (short or long term) to prevent hyperglycemia
  • Ketosis UNcommon (except in stress or infection)
  • Hyperglycemic hyperosmolar nonketotic syndrome (HHNS) can be an acute complication 

9

What is gestational diabetes mellitus?

  • Onset during pregnancy; usually in the 2nd or 3rd trimester
  • Due to hormones secreted by the placenta, which inhibit the action of insulin
  • Above-normal risk for perinatal complications especially macrosomia (abnormally large babies)
  • Treated with diet or insulin (if needed) to strictly maintain normal blood glucose
  • 2-5% of all pregnancies
  • Glucose intolerance transitory but may recur in future pregnancies
  • 30-40% develop overt diabetes within 10 years (usually type II; esp. if obese)
  • Risk Factors: obesity, >30 years, family history, previous large babies (>9lb)
    • Screening Tests on all women at 24-28 weeks gestation

10

What are risk factors for gestational diabetes mellitus?

  1. Obesity
  2. Age >30
  3. Family History of Diabetes
  4. Previous large babies (>9lbs)

11

When should all pregnant women be screened for gestational diabetes?

ALL women should be screened for gestational diabetes (glucose challenge test) between 24 to 28 weeks of gestation

12

What is secondary diabetes mellitus?

-Also known as diabetes mellitus associated with other conditions or syndromes

  • Depending on the ability of the pancreas to produce insulin, the patient may require treatment with oral antidiabetic agents or insulin
  • Accompanying/Causal Conditions:
    • Pancreatic Diseases
    • Hormonal Abnormalities
    • Medications (corticosteroids)
    • Estrogen-Containing Preparations

13

What is prediabetes (PrevAGT)?

Previous Classifications: previous abnormality of glucose tolerance (PrevAGT)

Characteristics:

  • Current normal glucose metabolism
  • Previous history of hyperglycemia (e.g. pregnancy, illness)
  • Periodic blood glucose screening after age 40 if there is a family history or symptomatic
  • Encourage ideal body weight, because loss of 10-15lb may improve glycemic control

14

What is prediabetes (PotAGT)?

Previous Classifications: potential abnormality of glucose tolerance (PotAGT)

Characteristics:

  • NO history of glucose intolerance
  • Increased risk of diabetes if...
    • Positive family history
    • Obesity
    • Mother of babies over 9lb at birth
    • Member of certain Native American tribes with high prevalence of diabetes (e.g. Pima)
  • Periodic blood glucose screening and encourage ideal body weight

15

Describe the characteristics of impaired glucose tolerance?

Previous Classifications: Borderline diabetes, Latent diabetes, Chemical diabetes, Subclinical diabetes, Asymptomatic diabetes

Characteristics:

  • Oral glucose tolerance test (OGTT) between 140mg/dL and 200mg/dL
  • Impaired fasting glucose defined by levels between 110mg/dL and 126mg/dL
  • 29% eventually develop diabetes
  • Above-normal susceptibility to atherosclerotic disease
  • Renal and retinal complications usually NOT significant
  • May be obese or non-obese (obese should reduce weight)
  • Should be screened for diabetes perdiodically

16

Describe why the diabetes classification system is dynamic.

1.) There can be many differences among individuals within each category

2.) EXCEPT for people with type I diabetes, patients may move from one category to another

17

What are the four different issues with insulin that can cause diabetes mellitus?

1.) Total lack of insulin

2.) Impaired release of insulin

3.) Inadequate or defective insulin receptors in body tissue

4.) Insulin that is either inactive or destroyed before it can become effective

18

What is the suspected cause of type I diabetes mellitus?

It is believed to be autoimmune in nature and result from a total lack of insulin due to destruction of pancreatic beta cells

  • Interaction between genetic component AND acquired component (autoimmune)

19

When is type I diabetes usually diagnosed?

Childhood

20

What is believed to be some of the causative factors of type II diabetes?

It is believed that there is an interaction between genetic components and acquired components (obesity, inactivity, high sugar diet)

  • Obesity and inactivity are the primary risk factors
  • Hyperglycemia is the typical result, despite the presence of insulin in the body

21

When is type II diabetes usually diagnosed?

It is usually diagnosed in adults >40 years but is being diagnosed in increasingly younger patients

22

What are the THREE P's that describe the symptoms of diabetes mellitus?

Polyuria (excessive urination)

Polydipsia (excessive thirst)

Polyphagia (excessive hunger

  • Other symptoms include...
    • Fatigue
    • Muscle Weakness
    • Poor Blood Flow

23

What are the common symptoms of type II diabetes?

1.) The THREE P's (Polyuria, Polyphagia, Polydipsia)

2.) Fatigue

3.) Impaired Blood Circulation

4.) Muscle Weakness

5.) Muscle Wasting

6.) Vision Changes (Blurred Vision)

7.) Numbness/Tingling in Hands or Feet (Neuropathy)

8.) Dry Skin

9.) Skin Lesions that are Slow to Heal

 

24

What are the common symptoms of type I diabetes?

1.) The THREE P's (Polyphagia, Polydipsia, Polyuria)

2.) Fatigue

3.) Muscle Weakness

4.) Poor Blood Circulation

5.) Nausea

6.) Severe Vomiting

7.) Abdominal Pains

25

What are common acute and long-term complications of diabetes mellitus?

Acute Complications:

  • Diabetic Ketoacidosis (mainly type I)
  • Hyperosmolar Hyperglycemic Nonketotic Syndrom (HHNS)
  • Hypoglycemia

Long-Term Complications:

  • Microvascular Disease (e.g. renal and retinal disease)
  • Macrovascular Disease (e.g. CHD, CVA, PVD)
  • Neuropathies

26

Which organ is responsible for the secretion of glucagon and insulin to help regulate blood sugar?

Pancreas

  • Islet of Langerhans Cells
    • Alpha Cells (20%): Glucagon
    • Beta Cells (70%): Insulin, Amylin
    • Delta Cells (<10%): Somatostatin
    • Gamma/F Cells (<5%): Pancreatic Polypeptide
    • Epsilon Cells (<1%): Ghrelin

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27

What is insulin?

-It is a hormone secreted by beta cells in the islets of Langerhans cells of the pancreas

  • Anabolic/Storage Hormone: insulin moves glucose from the blood into muscle, liver, and fat cells

28

How does insulin function once inside the cells?

1.) Transports and metabolizes glucose for energy

2.) Stimulates storage of glucose as glycogen in the liver and muscle cells

3.) Signals liver cells to stop the release of glucose

4.) Enahcnes storage of dietary fat in adipose tissue

5.) Accelerates transport of amino acids into cells

6.) Facilitates the transport of potassium into the cells

7.) Inhibits the breakdown of stored glucose, protein, and fat

29

Insulin facilitates the transport of ______, and _______ (an electrolyte) into the cells

Insulin facilitates the transport of glucose and POTASSIUM into the cells

30

What is glucagon?

It is another pancreatic hormone secreted by the alpha cells of the islets of Langerhances, which stimulates the liver to release stored glucose and thereby, increases blood sugar

  • Secreted in response to low blood sugar

31

In short _______ promotes hypoglycemia and _______ promotes hyperglycemia.

In short, insulin promotes hypoglycemia, and glucagon promotes hyperglycemia.

32

What is "basal" insulin?

-The pancreas continually releases a small amount of insulin during fasting periods (e.g. between meals or overnight)

  • 50% of the total insulin secreted daily is under basal conditions (the other half is in response to meals)
  • The estimated adult (70kg) basal insulin secretion rate ranges from 18-32 U/24hrs
  • Minutes after eating, the serum insulin level rises, peaking in 3 to 5 minutes and returning to baseline withing 2 to 3 hours
    • Nurses may need to manage insulin drips based on basal insulin secretion rates to attain glycemic control

33

What is glycogenolysis?

It is the breakdown of glycogen to glucose in the liver in response to blood sugar that has become too low.

  • It is the FIRST response to low blood sugar

34

What is gluconeogenesis?

After 8-12 hours without food, the liver forms glucose fom the breakdown of noncarbohydrate substances, including amino acids

  • This is a secondary response after glycogen stores have been depleted

35

Describe the etiology of type I diabetes mellitus.

  • Accounts for 5-10% of people with diabetes
  • Acute Onset
  • Commonly begins in childhood/young-adulthood (but can occur at any age)
  • Desctruction of the pancreatic beta cells
  • Combined genetic, immunologic, and environmental factors
  • Common underlying factor is genetic susceptibility/predisposition
  • Autoimmone Disease
  • Associated with certain human leukocyte antigen (HLA) types); increases risk by 3-5x
  • INITIATED by environmental factors such as viruses or toxins

36

Describe the course of untreated type I diabetes.

  • Beta cell destruction causes decreased insulin production, unchecked glucose production by the liver, and fasting hyperglycemia
  • Postprandial Hyperglycemia: occurs after meals since glucose derived from food cannot be stored in the liver
  • Exceeding Renal Glucose Threshold: usually when there is at least 180-200mg/dL of blood glucose, as kidneys cannot reabsorb all of the filtered glucose
    • Glycosuria: glucose appears in the urine
  • Osmotic Diuresis: glucose is an osmotic agent and water follows it, causing an excessive loss of fluids and electrolytes

37

What is the course of type I diabetes that typically leads to ketoacidosis?

  • Unrestrained glycogenolysis and gluconeogenesis: insulin normally inhibits these processes
  • Hyperglycemia: due to the insulin deficiency and unrestrained glycogenolysis and gluconeogenesis
  • Ketones: a byproduct of fat breakdown; an organic acid
  • Ketoacidosis: the life-threatening decrease in pH causing by excessive amounts of ketones present in the blood

38

What is the etiology of type II diabetes?

  • Make up 90-95% of those with diabetes
  • Commonly associated with old age/obesity; increasing in younger people (obesity epidemic)
  • Results from insulin resistance and impaired insulin secretion
  • Insulin becomes less effective in stimulating glucose uptake by the cells and at regulating glucose release by the liver
  • Exact mechanisms unknown; genetic factors
  • Increased amounts of insulin must be secreted to overcome insulin resistance and beta cells cannot keep up with increased demand for insulin
  • DKA UNCOMMON: usually enough insulin present to prevent
  • Hyperglycemic hyperosmolar nonketotic syndrome from uncontrolled type II

39

Why does type II diabetes often go undiagnosed?

  • Associated with slow, progress glucose intolerance and its onset may go undetected for many years
  • Symptoms are typically mild (fatigue, irritability, polyuria, polyphagia, polydipsia, poor wound healing, frequent infections, changes in vision)
  • Many are actually diagnosed as a result of routine laboratory tests or during opthalmoscopic examinations (screening is important!)
  • Complications:
    • Microvascular (diabetic retinopathy, neuropathy, nephropathy)
    • Macrovascular (peripheral vascular, coronary disease, stroke)

40

What is the etiology of gestational diabetes mellitus (GDM)?

  • Secretion of placental hormones, which causes insulin resistance
  • Physiologic stress of pregnancy reveals existing glucose tolerance abnormalities that were not apparent prior to pregnancy
  • Occurs in as many as 14% of pregnant women
  • Risk Factors:
    • Obesity
    • Personal History of GDM
    • Family History of Diabetes
    • Birth of Baby >9lbs

41

Describe the recommended screening procedures for gestational diabetes mellitus (GDM).

  • Risk assessment for gestational diabetes should be completed during the
  • High Risk: tested as soon as possible and then retested between 24-28 weeks if initial glucose was normal
  • Low-Moderate Risk: initially tested between 24-28 weeks of pregnancy

42

Describe the recommended management of gestational diabetes.

  • Initial Management: diet, exercise, blood glucose monitoring; insulin if hyperglycemia persists
  • Blood Glucose Goals: maintain tight regulation
    • Before Meals: 95 mg/dL or less
    • 1hr After Meals:  less than 130-140 mg/dL
    • 2hr After Meals: less than 120 mg/dL
  • Education: counseling to maintain ideal body weight and exercise regularly
    • High risk of developing type II diabetes w/in 10 yrs
    • After delivery, blood glucose levels usually return to normal

43

Why is screening for type II diabetes so important?

Type II diabetes is frequently NOT diagnosed until complications (which can be permanent) are present

  • At-Risk Children: should be screened starting at age 10

44

Describe the important risk factors for type II diabetes.

  • Family history of diabetes
  • Obesity (BMI>25)
  • Ethnicity (African Americans, Latinos, Native Americans, Asian Americans, Pacific Islanders)
  • Age (>45 years)
  • Previously ID'd impaired glucose tolerance or impaired fasting glucose
  • Hypertension (>140/90 mm Hg)
  • Low HDL cholesterol (<35 mg/dL) and/or high triglyceride levels (>250 mg/dL)
  • History of gestational diabetes or delivery of babies over 9 lbs

45

What are the incidence rates of diabetes among various ethnicities?

  • Native Americans/Alaska Natives (16.5%)
  • Blacks (11.8%)
  • Hispanics (10.4%)
  • Asian Americans (7.5%)
  • Whites (6.6%)

-By 2050, nearly half of the U.S. population will be other than white, which makes identifying ethnic risk factors important

46

How does hyperglycemia affect the immune system?

  • Impairs immune function (decreases white blood cell function)
  • Promotes inflammation
  • Increases blood viscosity
  • Favors growth of yeast organisms
  • Associated with blood vessel wall changes resulting in increased risk for infection
  • Recurring infections
  • Microvascular and macrovascular complications
  • Foot ulcers; slow-healing wounds

47

What is a normal fasting glucose for a NONdiabetic?

  • 80-90mg/dL with a range of 70-120mg/dL

48

What is the fasting glucose level for prediabetes?

  • 100-125 mg/dL

49

What is the typical fasting plasma glucose (FPG) levels and random plasma glucose levels of diabetics?

  • Fasting Plasma Glucose (FPG): 126 mg/dL or higher
  • Random Plasma Glucose Levels: 200 mg/dL or more on more than one occasion

50

Which test for diabetes mellitus is no longer recommended for routine clinical use in nonpregnant adults?

The oral glucose tolerance test (OGTT) is no longer recommended for routine clinical use in nonpregnant adults

51

What are some important gerontologic considerations of diabetes mellitus?

  • Greatest increase in incidence is occuring in the elderly (people with diabetes are living longer)
  • Possible Causes: poor diet, physical inactivity, altered insulin secretion, insulin resistance
  • Elevated blood glucose levels commonly appear in the 5th decade of life and increase with aging
  • Other than those with overt diabetes, about 20% of those over the age of 65 have hyperglycemia
  • Likely Comorbidities That Complicate Diabetes: HTN, CVD, CVA
  • Normal physiologic changes of aging may mask the symptoms of diabetes, making diagnosis more difficult!
  • Increased Complication Risks: polypharmacy, depression, cognitive impairment, urinary incontinence, falls, chronic pain

52

How should goals in diabetes treatment be tailored for the elderly population?

  • The goals of diabetes treatment may need to be altered when caring for elderly patients
  • Focus is on QUALITY of life issues such as maintaining independent functioning and promoting general well-being
  • Avoidance of prolonged hyperglycemia
    • BUT avoid striving for strict control of blood glucose levels (may increase chances of severe hypoglycemia)

53

List age related changes that may affect diabetes and its management for gerontological populations.

  • Sensory: decreased vision and smell, taste changes, decreased proprioception, diminished thirst
  • Gastrointestinal: dental problems, appetite changes, delayed gastric emptying, decreased bowel motility
  • Activity/Exercise Pattern: more sedentary
  • Renal Function: decreased function and drug clearance
  • Affective/Cognitive: medications/meals omitted or taken erratically
  • Socioeconomic Factors: fad diets, loneliness/living alone, lack of money/lack of support system
  • Chronic Diseases: HTN, arthritis, neoplasms, acute/chronic infections
  • Potential Drug Interactions: use of another person's medications, consulting mult. HCPs for different illnesses, alcohol use/abuse

54

What are the five components of diabetes management?

The therapeutic goal for diabetes management  is to achieve normal blood glucose levels (euglycemia) without hypoglycemia, while maintaining a high quality of life

1.) Nutrition

2.) Exercise

3.) Monitoring

4.) Medication

5.) Education

55

Why is nutrition one of the foundations of diabetes management?

  • Nutrition management alone is often associated with reversal of hyperglycemia in type 2 diabetes
  • Make sure to consult a registered dietition to educate the patient; as the nurse give further education and support
  • The MOST IMPORTANT dietary management objectives are...
    • Control of total caloric intake to attain or maintain a reasonable body weight
    • Control of blood glucose levels
    • Normalization of lipids and blood pressure to prevent heart disease, CAD, CVD, and PVD
    • Meet and maintain energy needs
    • Provide all essential food constituents necessary for optimal nutrition

56

Assessing the Patient With Diabetes: History

  • Symptoms related to diagnosis of diabetes, hyperglycemia, and hypoglycemia (OPQRST)
  • Results of any blood glucose monitoring
  • Status, Symptoms, and Management of Chronic Complications of Diabetes (eye, kidney, nerve, GI, GU, sexual, peripheral vascular, foot issues)
  • Adherence/ability to follow prescribed dietary management plan, exercise regimen, prescribed pharmacologic treatment
  • Use of tobacco, alcohol, and prescribed/OTC meds
  • Lifestyle, cultural, psychosocial, and economic factors that may affect diabetes treatment
  • Effects of diabetes or its complications on functional status (e.g. mobility, vision)

57

Assessing the Patient With Diabetes: Physical Examination

  • Blood Pressure (sitting and standing to detect orthostatic changes)
  • Body Mass Index (height and weight)
  • Funduscopic Examination/Visual Acuity
  • Skin Examination (lesions, insulin-injection sites, acanthosis nigricans, discoloration esp. in lower limbs)
  • Foot Examination (lesions, signs of infection, pulses, sense of feeling)
  • Neurologic Examination (vibratory and sensory examination using monofilament, deep tendon reflexes)
  • Oral Examination

58

Assessing the Patient With Diabetes: Laboratory Examination

  • HgbA1c
  • Fasting Lipid Profile
  • Test for Microalbuminuria
  • Serum Creatinine Level
  • Urinalysis
  • Electrocardiogram

59

Assessing the Patient With Diabetes: Need for Referrals

  • Ophthalmology
  • Podiatry
  • Dietitian
  • Diabetes Educator
  • Others if indicated

60